Open Cholecystectomy for the New Learner-Obstacles and Challenges.

BACKGROUND: Laparoscopy has become the standard of care in most general surgery procedures. This has led to a decrease in the number of open surgical procedures for surgical training, particularly as senior surgeons retire. The aim of this study was to evaluate the impact of retiring senior surgeons on our residents' operative experience. METHODS: Cholecystectomies performed between Jan 2010 and Dec 2016 were retrospectively reviewed. Surgeons training residents were divided into two groups based on their training experience. Group 1 were trained in the prelaparoscopic era, and group 2 were trained during the age of laparoscopy. We then evaluated the impact of retirement on the number of open cholecystectomies performed. RESULTS: There were 4555 laparoscopic cholecystectomies performed at our institution over a 7-year period. Overall conversion rate was 1.5% (66/4555). Conversion rates were higher in group 1 as compared to group 2. The analysis of the number of open cases performed by each graduating resident showed reduction in the number of open cholecystectomies performed over time. CONCLUSION: The decline in the number of open cholecystectomies creates a challenge for the training of general surgery residents. To compensate, we have employed simulation curriculum with the use of cadaveric surgical anatomy courses. Additionally, with transplant curriculum, open cholecystectomy experience has increased with liver transplant exposure. Continued laparoscopic experience has also shown that advanced laparoscopic techniques such as top down dissection laparoscopically have decreased the need for conversion to open and are skills that graduating residents possess.

Relationship between BI-RADS and the Results of the Wire-Guided Percutaneous Localization for Non-Palpable Breast Lesions.

INTRODUCTION: The aim of this study is to evaluate the relationship between Breast Imaging Reporting and Data System and surgical biopsies that may increase effectiveness of wire-guided percutaneous localizations for non-palpable breast lesions. METHODS: A retrospective review of a sample of 149 patients who underwent wire-guided localization with wide local excision for non-palpable breast lesions at the authors' institution between January 2013 and April 2016. After IRB approval, sample patients' records were reviewed and data were collected concerning their radiological, histological and surgical characteristics. RESULTS: One (0.67%) complication occurred related to wire migration. There were nine (6.04%) recorded cases of seroma and three (2.01%) cases of hematoma. Breast Imaging Reporting and Data System (BI-RADS) Category 4 was found to have a positive predictive value of 28.4% for breast cancer. Under Category 4 subcategorization 4A, 4B, and 4C, the number of positive lesions were two (6.89%), three (10.34%) and five (17.24%), respectively. Forty (78.43%) of the 51 patients with cancer had negative (i.e., non-cancerous) margins compared to 11 (21.57%) cases that had positive margins after the first procedure. CONCLUSION: The BI-RADS Category 4 encompasses the majority of lesions, with approximately 70% of such biopsies lesions later found to be benign. A subcategorization of BI-RADS 4 needs further clarification in distinguishing benign vs malignant imaging characteristics. Future retrospective studies designed to identify benign vs. malignant lesions, confirmed by validating prospective studies, will better clarify a new subcategorization of BI-RADS Category 4, thus allowing surgeons and radiologists to make the best surgical recommendations for their patients.

Single-site robotic cholecystectomy: comparison of clinical outcome and the learning curves in relation to surgeon experience in a community teaching hospital.

BACKGROUND: The aim of this study was to analyze the experience of two surgeons who have different laparoscopic skills and case volume, with single-site robotic cholecystectomy (SSRC) and evaluate their learning curves. METHODS: All SSRCs performed between March 2013 and April 2015 were retrospectively reviewed. The patients were divided among two surgeons based on the surgeon's level of laparoscopic skills and case volume. Surgeon 1 had experience in advanced laparoscopy while surgeon 2 had basic laparoscopic skills. Patients' demographic data, intraoperative and short-term postoperative results were assessed. RESULTS: The analysis included 102 patients for surgeon 1 and 15 patients for surgeon 2. There were no major or minor complications in either cohort. Operative time was significantly longer for surgeon 2, conversion to laparoscopy rate was 4% for surgeon 1 compared to 20% for surgeon 2, P = 0.044, which is statistically significant. CONCLUSIONS: SSRC is an easy and safe procedure that can be quickly learned and performed in a reproducible manner by surgeons with experienced laparoscopic skills and greater case volume.

Synchronous perforation of non-Hodgkin's lymphoma of the small intestine and colon: a case report.

INTRODUCTION: Primary non-Hodgkin's lymphoma of the small and large bowel presenting as a perforated viscus entity with peritonitis is extremely rare. A thorough literature review did not reveal any cases where primary lymphoma of the jejunum presented with perforation and peritonitis synchronously with primary lymphoma of the descending colon. CASE PRESENTATION: This report concerns a 64-year-old Caucasian woman admitted with severe abdominal pain and fever. An emergency laparotomy revealed a large mass with perforation in the proximal jejunum with intense mesenteric thickening and lymphadenopathy. The descending colon was edematous and covered with fibrinous exudate. Histopathological examination of the resected segment of jejunum revealed a T cell non-Hodgkin's lymphoma. On post-operative day 10, a computed tomography scan of our patient's abdomen and pelvis showed leakage of contrast into the pelvis. Re-exploration revealed perforation of the descending colon. The histopathology of the resected colon also showed T cell non-Hodgkin's lymphoma. Her post-operative course was complicated by acute renal and respiratory failure. The patient died on post-operative day 21. CONCLUSIONS: Lymphoma of the small intestine has been reported to have a poor prognosis. The synchronous occurrence of lesions in the small intestine or colon is unusual, and impacts the prognosis adversely. Early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma.